BSPR 2011 Abstracts
BSPR 2011 ANNUAL MEETING ORAL PRESENTATION ABSTRACTS
IS ROUTINE CHEST X-RAY NECESSARY FOLLOWING PERCUTANEOUS CENTRAL VENOUS CATHETER INSERTION IN CHILDREN?
Chowdhury M, Gordon H, Nicholls E.
Ultrasound guided percutaneous insertion of central venous catheters (CVCs) is now the gold standard (NICE). There is however a paucity of data in children examining the utility of routine CXRs using this method. Our aim is to quantify the morbidity associated with the technique and examine whether routine CXR is justified.
A retrospective review of 150 consecutive children who underwent CVC insertion was performed over a four-year period. All lines were inserted, by a single team, percutaneously. The venepuncture was performed using ultrasound guidance with a high-frequency linear transducer and line inserted using Seldinger technique under fluoroscopy guidance. All patients underwent routine CXR post-operatively. The clinical notes and radiological reports of each patient were reviewed and data extracted with respect to demographics, clinical indication, CXR findings, and clinical outcome. Outcomes of patient’s who underwent portacath versus Hickman lines were also compared.
Amongst 150 children, of median age 12years (range 4-16), 56% were male and 44% female. All central lines (with 60.5% being Hickman lines and 39.5% Portacaths) were inserted via an internal jugular venous approach. The clinical indication for line insertion was chemotherapy (85.7%), intravenous antibiotics (9.5%), total parenteral nutrition (2.4%), and poor peripheral access (2.4%). A total of 148 patients (98.7%) showed no complications, either clinically or on CXR. Of the remaining two patients (1.3%), both had their complications detectable on CXR; one had an asymptomatic pneumothorax that did not require treatment and one had a slight kink. The type of line inserted did not influence the rate of complications.
This study demonstrates that percutaneous insertion of CVCs is very safe if performed under ultrasound and fluoroscopy guidance. The low morbidity (<1%) factors which alter clinical management, additional undue radiation exposure and stress to the child, cumulatively suggests that routine post-operative CXR is not indicated.
The Postnatal Management Of Congential Lung Disease & Correlation With Its Antenatal Diagnosis
Dr Christopher Rodriguez (ST5 Radiology),Dr Susan Morris (Consultant Radiologist)
University Hospital of Wales, Cardiff
1. There are no clear postnatal imaging guidelines for antenatally diagnosed congenital lung lesions. In our centre, the current recommendation is that neonates undergo a CXR at birth and a contrasted CT of the thorax at 1 month of age. We discuss whether this is optimal.
2. To develop and propose an imaging strategy guideline for such cases.
3. To determine the antenatal diagnostic accuracy of antenatally diagnosed congenital lung lesions.
Methods and Materials:
Retrospective case series of all antenatally diagnosed congenital lung lesions for Wales, as per Congenital Anomaly Register & Information Service for Wales for the last 5 years.
Antenatal and postnatal imaging reviewed from local Picture Archiving and Communication System.
There were a total of 62 cases. Fifty-one of these were diagnosed antenatally. Twenty-nine were congenital cystic adenomatoid malformations (CCAM), 12 were bronchopulmonary sequestrations (BPS) and 10 were made up by other/ complex lesions. The positive predictive value for antenatal diagnosis of CCAM and BPS was 69% and 92% respectively. Forty-three patients received a postnatal CT scan of the thorax – approximately half of these were performed at 1 month of age, the remaining half being performed at variable ages. 3 patients had a second CT scan immediately prior to surgery.
The age for surgical intervention in patients with congenital lung lesions is variable and depends on a variety of factors. We propose that all patients have a CXR at birth and a contrasted CT prior to surgical intervention. This reduces relative radiation doses and avoids unnecessary irradiation.
CAN PULMONARY SEQUESTRATION CHARACTERISATION DEFINE ITS NATURAL HISTORY AND MANAGEMENT STRATEGY? A SYSTEMATIC REVIEW OF THE EVIDENCE
Chowdhury M, McHugh K, Pierro A John Radcliffe Hospital, Oxford and Great Ormond Street Hospital, London
The natural history of pulmonary sequestration (PS) remains controversial. Reported spontaneous involution questions whether removal of all lesions is appropriate. Our aim is to examine whether lesion characterisation can help predict outcome.
A literature review was performed (Medline, Ovid, Cochrane databases) to identify studies examining outcome of PSs. Relevant articles were reviewed with respect to methodological quality, lesion characteristics, and outcome based on conservative management versus intervention. Results (mean±SEM) were analysed with ANOVA and Chi-square tests.
Review of 783 articles (1959-2011) identified 149 relevant studies (602 patients). PSs were intra-thoracic in 91.2% (68.4% intralobar, 22.8% extralobar) and intra-abdominal in 8.8%. A significant associated anomaly was three times more common with extralobar than intralobar lesions.
Presentation: 51.1% were detected antenatally (mean 21weeks), 38.8% of whom became symptomatic at birth, all with respiratory distress. The presence of mediastinal shift, pleural effusion or hydrops antenatally (42.4% prevalence), represented an 84.2% positive predictive value for the patient becoming symptomatic postnatally.
48.9% were identified postnatally (mean age 17.2years), 74.6% with symptoms and 25.4% incidentally. Intra-abdominal PSs were less likely to cause symptoms (14.6%) than intralobar (68.0%, p<0.001) and intrathoracic extralobar lesions (82.4%, p<0.001), with no difference between intrathoracic sites.
Involution: Partial/ complete spontaneous involution is more likely in (1) those diagnosed antenatally than postnatally (18.4% vs. 6.9%; p=0.0006), (2) intra-abdominal (40.6%) than intralobar (16.2%; p=0.003) or intrathoracic extralobar lesions (1.6%; p<0.001), (3) solid/ mixed than cystic lesions (51.7% vs. 7.4%; p<0.001).
Treatment: Lesions were excised or embolised for symptoms (51.2%), suspected alternative diagnosis (7.6%) or concurrent treatment of a comorbidity (3%). The remaining 38.2% of lesions treated were asymptomatic, although 84.7% had the diagnosis confirmed radiologically.
PS characterization can help predict outcome, is relevant for counselling and refining management strategy, and may obviate unnecessary surgery in select confirmed asymptomatic abdominal cases.
A review of unexpected ultrasonographical findings in the investigation of suspected empyema in the paediatric population.
Dr A Rayner, MBBS BSc, MRCP (UK), FRCR, Dr S Chakraborty, MBBS, MS, FRCS, FRCR Children’s Hospital, Oxford Radcliffe Hospitals NHS Trust, Oxford,
· To recognise that unilateral homogeneous opacification on a chest radiograph is not always due to the presence of pleural fluid.
· To be aware of the alternative diagnoses that may present in a similar manner to an empyema.
· To understand the important role of thoracic ultrasound in the diagnosis of suspected parapneumonic effusions and empyemas.
Although still uncommon, pleural infections in the paediatric population are becoming more prevalent within the UK1,2 with an incidence of parapneumonic effusion and empyema of 3.3 per 100,000 children3. They are found more commonly in boys than girls, in infants and in the winter and spring months4.
Current BTS guidelines5 state that if there is clinical suspicion of a parapneumonic effusion or there has been no response to pneumonia treatment after 48 hours then a chest radiograph should be performed. A radiograph alone cannot differentiate between a parapneumonic effusion and an empyema. Therefore, if an apparent effusion is shown, then chest ultrasonography must be performed to confirm the radiographic findings.
Although ultrasound cannot reliably establish the stage of pleural infection,6 it can estimate the size of the effusion, differentiate free from loculated pleural fluid, and determine the echogenicity of the fluid.7 Also, as demonstrated in this presentation, ultrasound can demonstrate several other pathologies that on radiography alone are indistinguishable from a pleural collection. Some of these are life threatening conditions and therefore radiologists should be aware of their sonographic appearances.
Clinical Findings/Procedure Details
We present the findings of experience of thoracic ultrasound performed at our centre in the suspected diagnosis of empyema. Pathologies detected other than empyemas included: severe pulmonary infections (extensive consolidation, necrotising pneumonia and pulmonary abscesses) and solid tumours (chest PNET, synovial sarcoma, malignant solitary fibrous tumour of the lung, teratoma and pleuroperitoneal blastema). We present the radiographic, ultrasonographic and, if performed, computed tomography findings of these cases.
Although empyemas are becoming increasingly common in the paediatric population, alternative causes for unilateral opacification of the hemithorax on chest radiographs should always be considered.
1. Rees JH, Spencer DA, Parikh D, et al. Increase in incidence of childhood empyema in West Midlands, UK. Lancet1997;349:402
2. Playfor SD, Smyth AR, Stewart RJ. Increase in incidence of childhood empyema.Thorax1997;52:932
3. Hardie W , Bokulic R, Garcia VF, et al. Pneumococcal pleural empyemas in children.Clin Infect Dis1996;22:1057–63
4. Freij BJ, Kusmiesz H, Nelson JD, et al. Parapneumonic effusions and empyema in hospitalized children: a retrospective review. Pediatr Infect Dis1984;3:578–91
5. I M Balfour-Lynn et al, BTS guidelines for the management of pleural infection in children. Thorax 2005;60:i1-i21 doi:10.1136/thx.2004.030676
6. Kearney SE, Davies CWH, Davies RJO, et al. Computed tomography and ultrasound in parapneumonic effusions and empyema. Clin Radiol2000;55:542–5 .
7. King S , Thomson A. Radiological perspectives in empyema. Br Med Bull2002;61:203–14.
Paediatric cervical spine CT in trauma
Are we finding any genuine pathology or are clinicians and radiologists being misled by normal variations?
Akhtar S1, Beeston E2, Amonkar SJ3
Pennine Acute Hospitals NHS Trust.
1 Radiology ST2, North West Deanery School of Radiology, [email protected]
2 Foundation Year Trainee 1, Royal Oldham Hospital
3 Consultant Paediatric/ General Radiologist, Pennine Acute Hospitals NHS trust
CT usage to assess suspected paediatric C-spine trauma is increasing. As this involves significant radiation, we wanted to investigate whether plain films were still being performed (and if so how they were being interpreted), the indications for CT, correlation of C-spine injury with other injuries and if normal variants in the paediatric C-spine were being misinterpreted.
A retrospective review of all paediatric trauma C-spine CTs undertaken between 2008-2011 in a large NHS trust (compromising of four hospitals with individual A&E departments) was performed. Demographic data, clinical indications, radiation dose and imaging results were collected. In addition, where available, plain film and CT images were reviewed.
In total 78 C-Spine CTs were performed in 77 patients. Pedestrian RTA was the main indication for imaging (49%). Plain films of the cervical spine were performed in 50 patients (65%). Of these, 27 were initially reported as normal and 23 abnormal. On review, 26 plain films were felt to be inadequate for safe clearance of the C-spine. Eight CT C-spines were originally reported as abnormal, but on review, variants that appeared to cause confusion were pseudosubluxation, ossification centres and vascular markings. Only one patient had an unstable injury. Forty-nine patients also had a CT brain; all 23 who had an abnormal brain CT had a normal CT C-spine.
Where performed, it was apparent that limited views or misinterpretation of normal variants on the radiograph resulted in a CT being performed. Variations in the paediatric C-spine on CT also appeared to cause some issues. However, out of the 78 scans performed, only one unstable fracture was identified; this was readily seen on plain film. Also, significant head trauma does not appear to equate to C-spine injury.
Though we accept that in certain scenarios CT is required, further education and awareness on plain film interpretation may reduce the number of CTs performed and ultimately the radiation dose to the child.
Screening For Developmental Dysplasia of the Infant Hip
Dr Rosemary Arthur, Leeds.
The NHS Newborn & Infant Physical Examination Programme (NIPE) offers parents of newborn babies in England the opportunity to have their child examined shortly after birth. There are four relevant screening elements: examination of the heart, hips, eyes and testes in boys. New standards and competencies were published for this programme in March 2008.
Ultrasound assessment is now recommended for all infants with clinical hip abnormality detected on the routine clinical examination and or all babies considered to be at risk of developmental dysplasia of the hips.
This paper will outline the proposed clinical pathway and the steps being taken to improve the consistency of the Hip Programme. Details will be given of the proposed clinical pathway, draft report form, the development of training programmes and steps being taken to develop national standards to ensure a high standard of ultrasound screening is undertaken in all regions.
Internet based teleconferencing – will it help us?
Ramdas Senasi and Iwan Roberts
Sheffield Childrens Hospital
We wanted to organise meetings to discuss on-call paediatric radiology and keep the radiology training rotation updated on current issues within the paediatric radiology department. Apart from the paediatric slot and the odd on call commitment, most trainees have either infrequent or very limited exposure to paediatric radiology on a dad to day basis. As a proportion of trainees will go on to work in district general hospitals, keeping abreast with current issues in a self reflective and easy to digest manner is important. Pre-FRCR trainees meet for weekly teaching but other trainees are often scattered around our deanery in South Yorkshire. Added to this, the main teaching hospitals are based at four different centres around the city. We wanted to find a way to deliver regular paediatric education and clinical governance in a logistically feasible way.
Internet-based teleconferencing involves data and image sharing via the Internet while sound is via a conference phone. The system can accommodate up to 50 participants the cost can be less than £5 per hour per participant. There is great flexibility, as the system does not rely on fixed video-conferencing systems. Confidentiality issues relating to the Internet have been addressed.
We have used British Telecom’s Webex system to deliver the meetings. Remote presentation requires some adjustment but offers tremendous opportunities. Administrative issues including security are presented and the implications for the use of this system are discussed. We will also present the feedback from trainees. We hope to see web based conferencing as an extra tool in delivering education and clinical governance in an ever changing service orientated environment.
Validation of a CT Based Finite Element Bone Model for Investigating Mechanisms of Injury in Child Abuse
Emerson N1, Carre M1, Reilly G1, Morris H1, Offiah AC2, 3
1, 2. University of Sheffield. 1. Department of Engineering 2. Department of Child Health 3. Sheffield Children’s NHS Foundation Trust
Recently, finite element (FE) models based upon high resolution three- dimensional computed tomography (CT) images have been used to assess not only the mechanical properties of bone, but also the performance of its microarchitecture and even the effectiveness of treatments for bone fracture.
To investigate whether the geometry and material properties of mid-shaft cortical bone calculated via CT imaging can be used to determine the location of fractures under prescribed test conditions in an FE model.
Methods & Materials:
Four porcine tibiae were imaged with a spiral CT (GE VCT 64 multi- slice) scanner. FE models were then created for each bone, allowing the correlation of specific geometry between FE and laboratory testing. Endplates were drawn in a CAD package and amalgamated with the cortical bone at the start of the metaphyseal region to replicate the constraints used in laboratory testing and to isolate the mid-shaft region.
FE test results were validated by comparison with matched loading tests of each scanned bone within a laboratory setting. The loading tests were conducted by the application of torsional forces to each bone specimen until fracture occurred.
Results: Finite element model predictions of torsional rigidity correlated significantly with experimental torsional rigidity, validating the modelling process for future testing methods.
Conclusions: The use of FE analysis to determine failure mechanisms has great potential for use as a tool in fracture studies. Having validated the technique on a porcine model, we shall now conduct tests based on CT images of infants and children in order to improve our current understanding of mechanisms of injury in infants. In particular the technique may ultimately prove to be important for the validation of mechanisms of injury put forward by carers in the context of suspected child abuse, not only for shaft fractures, but also for fractures at other sites.
Mechanisms of Injury in Children under the Age of Three: A Pilot Study
Hume J1, Gibbs S2, Sprigg A3, Burke D2, Offiah AC1, 3
1 University of Sheffield, Department of Child Health 2, 3 Sheffield Children’s NHS Foundation Trust 2) Emergency Department 3) Radiology Department
Children less than three years of age are particularly vulnerable to physical abuse, which can be extremely difficult to diagnose. Knowledge of the mechanisms of accidental injury in this age group is invaluable when attempting to exclude abuse, but is poorly documented. This is a pilot study to determine the feasibility of obtaining such information on a national level.
Prospective interview of consented carers and review of radiographs of children under the age of 3 years attending our Emergency Department (ED) with a suspected accidental skeletal injury. Epidemiological data and the mechanism of injury involved was analysed in relation to the diagnosed injury.
We recruited 50 out of a possible 64 patients (78%) over a two month period. The majority of injuries were in the 1-2yr olds (48%), followed by the 2-3yr olds (32%), while only 20% of the total presentations were found in <1yr olds. 84% were of white British origin. The most common site of injury was the head (54%). Upper and lower limbs accounted for the remaining injuries, 26% and 16% respectively. Mechanisms of injury included fall/trip (70%), blunt injury (10%), trap (8%), swing/lift/pull (6%) and unknown (6%). Fractures were confirmed in 5 of 14 patients who required radiographs (distal phalanx, humerus, radius, tibia and fibula).
The sensitive subject matter does not cause parents to withhold consent and interviews can be conducted successfully in the ED. Children < 1yr very rarely present to the ED with injuries and infrequently require radiographic imaging.
The use of MRI contrast agents in children: A survey of current practice in England, 2011
Anisa Rouhipour1, Nurul Jamalul-lail1, Jeannette K Kraft2
School of Medicine1, University of Leeds and Clarendon Wing Radiology Department2, Leeds Children’s Hospital
Nephrogenic Systemic Fibrosis is a rare but incurable life threatening condition, associated with Gadolinium based contrast agents in patients with renal impairment. Cyclical contrast agents, such as Dotarem are regarded safer compared to linear agents, such as Magnevist.
To assess the use of contrast agents in children
A survey of MRI units in England (obtained from www.nhs.uk) covering choice of contrast agents in children, licensing awareness and screening procedures for renal disease.
150 MRI units were contacted, 120 took part of which 85 reported to be undertaking MRIs in children. 36% (31) of the 85 units were preferentially using a ‘high risk’ linear agent over a low risk (60%) or medium risk (4%) agent. 14% (13) of 85 units use safer agents ‘off label’ knowingly. A further 47% (40) use a not fully licensed agent as first line. With regards to renal function testing, 14% of 85 units were not testing, 27% selectively test patients and 69% of units test all patients. 16% (15) of 85 units were not questioning parents about renal problems in the patients and 38% (35 units) did not require clinicians to report renal disease when requesting a scan requiring gadolinium.
High risk agents are still used in children. Many units appear not to know about licensing restrictions of Dotarem in children under 2 years of age. Practice regarding renal function testing is very variable.
The use of water-soluble contrast enemas in the diagnostic pathway of infants who fail to pass meconium, or who are suspected of having Hirschsprung’s disease: five-years of experience from Oxford, UK.
Jonathan Stedman, Francesca Castillo†, Jamie Franklin and Subhasis Chakraborty.
The Departments of Radiology and Paediatric Surgery†
John Radcliffe Hospital Oxford
To evaluate the use of water-soluble contrast enemas (WSCE) in the diagnostic workup of patients who fail to pass meconium or who are suspected of having Hirschsprung’s disease (HD), and estimate the diagnostic performance of WSCE for HD.
A retrospective cohort study of infants under 1 years, who had undergone WSCE between March 2006 and March 2011. On the basis of their WCSE patients were classified into three groups: 1) Radiological features of HD; 2) Alternate diagnosis to account for symptoms and 3) No features of HD or other pathology. For each patient, a review of the case-notes and any subsequent histopathology was performed; this formed the basis of the composite reference standard for the diagnosis of HD. Patients were excluded where there was duplication, confounding features from coexisting bowel pathologies, or no follow-up data was available.
157 infants underwent WCSE in the study period. 59 patients were excluded and 88 infants were subsequently included in the study. The median age was 4 days (0 to 336). In Group 1 (n=31), all patients underwent rectal suction biopsy (RSB). 20 had a final diagnosis of HD, 2 had an alternative diagnosis and 9 not found to have bowel pathology at histology and/or follow-up. In Group 2 (n=21), 8 underwent RSB. No patients had HD. 20 were confirmed as having an alternative diagnosis (consistent with that made by radiology) and 1 was not found to have bowel pathology. In Group 3 (n=36), 25 had RSB, 3 patients had HD, 8 had an alternative diagnosis and 25 did not have bowel pathology.
The overall sensitivity, specificity, PPV and NPV of WSCE for HD was 87% (20/23; 95% CI 65-97), 83% (54/65; 95% CI 71-91%), 65% (20/31; 95% CI 45-80%) and 94% (54/57; 95% CI 84-99%), respectively.
Conclusion: As in the prior literature our results shows that WCSE cannot be used to exclude or confirm the diagnosis of HD, however it can play an important role in the diagnostic pathway when HD is suspected, in particular it may offer alternative diagnoses and where this is the case it can avoid unnecessary RSB.
When is a Crossing Renal Vessel Not a Crossing Renal Vessel?
Dr S Negus, Mr F Murphy, St George’s Hospital, Tooting
Congenital hydronephrosis is one of the commonest urological problems in childhood and can be due to both intrinsic and extrinsic causes. The commonest intrinsic cause, occurring in 1 per 1000-2000 births, is a muscular defect leading to pelviureteric junction obstruction (PUJO). An aberrant or accessory, renal artery which crosses the PUJ to the lower pole of the kidney is the commonest external cause for obstruction although the presence of such does not always cause PUJO.The surgical approach is dfferent for both causes.Ultrasound may be used to identify possible abrerant or accessory vessels but contrast enhanced, arterial phase CT imaging with multi planar reformatting, remains the mainstay for diagnosis. There is extensive literature regarding the radiological features of the 2 causes of hydronephrosis but this pictorial presentation seeks to emphasise the features seen when an aberrant vessel is coincidental, and not causative of the hydronephrosis.
Computed tomography angiogram: accuracy in renal surgery. Rabah DM et al. Int J Urol, 2009;16(10: 58-60
Evaluation of crossing vessels in patients with uretopelvic junction obstruction by means of helical CT. Mitsumori A et al. RadioGraphics, 2000; 20; 1383-1393
Pelvi-ureteric junction obstruction by crossing renal vessels: clinical and imaging features. Rigas A et al. BJU Int, 2003; 92 (1): 101-103
Air Enema Reduction – A Registrar Led, Protocol Driven Service is Safe and Effective.
Edward Hannon1, Samantha Negus2, Rosemary Allen2, Felim Murphy1, Bruce Okoye1. 1 Department of Paediatric Surgery, St George’s Hospital, Tooting. 2 Department of Paediatric Radiology, St George’s Hospital, Tooting.
Background / Purpose:
The British Society of Paediatric Radiology draft guidelines (2003) for air enema reduction stated it should ‘be attempted where the involved radiologist has the appropriate continuing experience’ and have a success rate of >65-70%. In the UK air enema is predominantly performed by consultant radiologists. At our institution air enema is strictly protocol driven and usually performed by senior registrars in radiology and paediatric surgery. The aim of this study was to assess the efficacy and safety of our registrar led protocol driven system.
A Retrospective review of all air enemas performed for intussusception between January 2005 and 2011 was carried out. Cases were identified from radiology databases and reviewed for grade of radiologist involved, outcome and complications. Failed enemas had case note review to establish end points. 145 air enemas were performed across the time period and 141 cases were analysed (54 girls, 88 boys). The median age was 9 months (range 3-107 months).
82% of air enemas were performed by registrars. Over the time period the registrar led reduction rate was 77.5%. There was a perforation rate of 1.4% and overall resection rate of 4.3%. We believe good reduction rates are the result of several factors including a team approach with direct surgeon involvement in reduction, a protocol driven service to ensure reproducibility and safety, and factors such as training and equipment.
A registrar led protocol driven service for air enema reduction of intussusception can be safe and effective.
BSPR MEETING 2011 POSTER PRESENTATION ABSTRACTS
“To Swallow or not to Swallow!”A pictorial review of paediatric Oesophageal Anomalies
Hedayati V., Sellars M., Allen P.
Paediatric feeding complaints are very common, especially in the neonatal period, and it is often difficult to differentiate normal behavioural issues from congenital or pathological abnormalities.
These can range from gastro-oesophageal reflux to complex fistulas or even vascular rings.
Delay in diagnosis can lead to weight loss and sometimes long term feeding difficulties as well as development of complications causing concurrent pulmonary or cardiac co-morbidities.
Clinical findings are often non-specific and therefore, radiology plays a pivotal role in diagnosis of these entities. Early detection then allows appropriate prompt management which in some cases requires urgent surgical intervention. Barium swallows are usually the initial investigation of choice and can allow the immediate diagnosis of the vast majority of diagnoses.
We present a pictorial review illustrating a wide range of both common and rare oesophageal anomalies within the paediatric population. Although, the majority include barium swallow images, we also include some specialised investigations such as a tube oesophogram as well as CT and MRI modalities to demonstrate further the abnormalities and highlight the pertinent imaging characteristics.
The review therefore will serve to increase confidence in diagnosing some common and rare oesophageal disorders. This will allow for prompt referral and the appropriate management to be instigated thus avoiding unnecessary long-term weight and feeding issues as well as other co-morbidities.
Time to ditch the lateral?
Dr G Clarke, Dr M Davies, Royal Alexandra Hospital, Paisley, Glasgow.
To assess the usefulness of the lateral film in the Chrispin Norman1 score (CNs) for assessment of disease severity and progression in children with cystic fibrosis (CF).
The lateral film is used to assess sternal bowing, diaphragmatic depression and spinal kyphosis – one point or two for each depending on severity.
There is a PA film only modified Chrispin Norman scoring system2 (mCNs) which has been validated for inter/intra observer variation and correlation with clinical condition and PFTs3.
In the authors’ opinion the lateral film seldom offers any additional information over the PA film alone, results in extra effort for radiographers, parents and children and increases the radiation dose in our most at risk group4.
The archived requests for the CNs assessment for all CF patients in the Clyde sector of Glasgow from 1999 to 2010 were retrieved. The scores are compared with what are effective mCNs in our cases. This was achieved by removing the score determined by the lateral film, except the score for diaphragmatic depression which is assessable on the PA film.
These results demonstrate that in 124 of the 184 cases no points were lost in the total score with our mCNs.
The lateral film contributed only one point on forty-three occasions, two on sixteen occasions and three on one occasion.
Overall the few cases with a score of 1-3 on the lateral which would be lost were cases with low overall scores, consistent with mild changes. As a result score reduction did not impact on management.
These results support our anecdotal impression of the low clinical yield of the lateral film. We recommend transition to the modified Chrispin-Norman scoring system and propose this is carried out nationally.
Vascular Anomalies: A Structured Approach.
Dr Claire Gowdy + Dr Louise Sweeney
Vascular anomalies are common and form a spectrum of disease with a wide range of clinical and imaging appearances. Doppler ultrasound and MRI form the mainstay of radiological imaging in such cases and together with the clinical appearance a diagnosis can usually be made. A multidisciplinary team approach to management is necessary and the treatment options vary according to the nature of the lesion with radiologists playing an important role in treating haemangiomas and vascular malformations.
The classification system generally accepted as standard today was provided by Mulliken and Glowacki in 1982 and modified by the International Society for the Study of Vascular Anomalies . We present cases from the Royal Belfast Hospital for Sick Children to illustrate this simple, structured classification system for vascular anomalies using medical photographs as clinical evidence complimented with MRI and/or Doppler ultrasound investigations.
Normal variation in the appearance of elbow ossification centres
SJ Goodwin, G Irwin, Royal Hospital for Sick Children, Glasgow
Aim: As described by Resnick (1), an exception to the usual sequence of appearance of the elbow ossification centres is recognised as a normal variant (2). Our aim was to establish whether other examples of exceptions to the usual ‘CRITOL’ order of ossification centre appearance could be identified from elbow radiographs performed at our institution.
Methods: Retrospective review of 500 consecutive paediatric elbow radiographs performed at our institution.
Results: 500 elbow studies were performed in 229 patients. 7 patients (3%) were identified in whom the ossification centres were demonstrated to have appeared in an alternative order to the usual 'CRITOL' sequence.
Discussion: We identified 5 cases in which the internal epicondylar centre had appeared before the radial head (figure 1), and 2 examples of the olecranon centre appearing before the trochlear centre (figure 2). Resnick described appearance of the trochlear ossification centre before the medial epicondylar centre as a normal variant, significant due to possible misinterpretation as a medial epicondylar injury. We did not identify any further examples of this variation. The vast majority of cases remained consistent with the usual ‘CRITOL’ sequence, illustrating that this rule remains a valuable tool in the analysis of paediatric elbow films, while normal variations are important to be aware of to avoid misinterpretation.
The Value of Plain Radiographs In The Investigation Of Back Pain In The Paediatric Population
Dr Christopher Rodriguez (ST5 Radiology),Dr Cindy Leung (ST2 Radiology), Dr Susan Morris (Consultant Radiologist)
University Hospital Of Wales, Cardiff
Back pain in the paediatric population is an increasing complaint and presents a diagnostic challenge. Diagnostic imaging often forms an important part of the patient’s work-up. The aims are:
1. To evaluate the imaging work-up of back pain in the paediatric population.
2. To determine the value of negative plain radiographs.
3. To discuss the relative merits of the different imaging modalities within an imaging “algorithm.”
All plain radiographs of the lumbar and/or thoracic spine in patients under the age of 16 performed during a 12 month period were identified using the Picture Archiving and Communications System. The indications and sources of the referrals were obtained from the clinical information provided on the request cards. Note was made of the patient’s ages, the x-ray reports and the outcome of any subsequent relevant imaging.
A total of 309 examinations were performed in 252 patients – 200 lumbar and 109 thoracic spine radiographs. The patient’s average age was 11.9 years. 160 radiographs were performed for pain, 106 for injuries and 43 for other indications. Of the radiographs performed for pain, 112 (70%) were reported as normal – 9 of these went on to have a MRI scan, 6 of which were normal. Of the 48 performed for pain with radiographic abnormalities, 17 underwent MRI scans, all of which demonstrated relevant abnormalities. Of the referrals from primary care 74% were normal and of those from secondary or tertiary care 63% were normal.
Radiographs are a good diagnostic test for the work-up of back pain in children with a high negative predictive value. Further imaging should be considered in those with specific clinical symptoms, while limiting radiation exposure.
URETERIC STENTING AS AN ADJUNCT TO SURGERY IMPROVES REGRESSION OF HYDRONEPHROSIS AND CLINICAL OUTCOME IN CHILDREN WITH PELVIURETERIC JUNCTION OBSTRUCTION
Chowdhury M, Elmalik K, Capps S.
Aim: To examine whether adjunct ureteric stenting improves radiological and clinical outcome following surgery for pelviureteric junction obstruction (PUJO).
Methods: We reviewed 105 children that underwent pyeloplasty for PUJO over two consecutive 5-year periods: 47 unstented pyeloplasties (UP) followed by 58 stented pyeloplasties (SP). Outcomes (expressed as mean±SEM) of both groups were compared with respect to (1) relief of PUJO and improvement in differential renal function (DRF), both measured by MAG3 renogram), (2) resolution of hydronephrosis (using serial ultrasound), (3) complications, and (4) length of hospital stay. Results were analysed using ANOVA and Chi-square tests.
Results: 55 patients (53.9%) presented with antenatal hydronephrosis, whilst 47 (46.1%) presented postnatally (at mean age 88.4±7.1months).
Renal function & drainage: Post-operative MAG3 demonstrated (1) successful relief of PUJO in all SPs and UPs, and (2) significant improvement in DRF in the 29 patients operated for poor function, with no significant difference between the two groups. DRF improved from 26.7±2.0% pre-operatively to 32.7±2.4% post-operatively (p=0.02) in SPs; and from 32.6±4.3% to 42.4±5.0% (p=0.01) in UPs.
Hydronephrosis: Pre-operative renal pelvis AP diameter in SPs (3.24±0.25cm) and UPs (3.21±0.28cm) was comparable (p=0.80). Following pyeloplasty, a significant improvement from these baselines occurred earlier in SPs (at 3.10±0.46months) than UPs (at 15.71±3.05months), p<0.01.
Complications: Surgical complications were significantly lower in SPs (0/58) than UPs (5/47; 10.6%), p=0.016. These were leakage (8.5%) and obstruction by blood clot (2.1%). However nine SPs (15.5%) developed stent-related complications including stent migration (8.6%), infection (5.2%), calculus (1.7%).
Hospital stay: SPs had significantly shorter stay (2.71±0.25days) than UPs (4.30±0.38days), p<0.01.
Conclusion: Adjunct ureteric stenting following pyeloplasty results in regression of hydronephrosis significantly earlier, shorter hospital stay and reduces surgical complications, particularly leakage, but at the expense of stent-related complications. The latter may be minimised by the use of external and/ or radiological-assisted antegrade stenting.
SPONTANEOUS INVOLUTION OF INTRA-ABDOMINAL PULMONARY SEQUESTRATIONS
Chowdhury M, McHugh K, Pierro A.
Aim: The natural history of pulmonary sequestrations (PS) remains controversial, with the majority being excised irrespective of site or symptomatology. Our aim is to describe the natural history of intra-abdominal PS detected antenatally.
Methods: Two patients with intra-abdominal PS were identified on foetal ultrasound. Their subsequent clinical and radiological courses were followed; the latter by serial antenatal and three-monthly postnatal ultrasounds and sonographic parameters including site, lesion size (volume) and morphology were recorded. Postnatally both patients also underwent tumour profile (urinary catecholeamines, serum alphafetoprotein and beta-HCG) and lesions further evaluated by postnatal CT, MRI and ultrasound-guided biopsy.
Results: Foetal ultrasound in the two patients revealed left suprarenal echogenic masses, detected at 20 and 22 weeks, with subsequent serial scans demonstrating both masses growing proportional to the foetuses. A differential diagnosis of an adrenal tumour or PS was made in both cases.
The neonates were born at 39 and 38 weeks gestation (weight 2600g and 2700g respectively). Postnatal USS confirmed both suprarenal masses as heterogeneously echogenic containing multiple cysts. In both patients tumour marker profiles were normal. PS was diagnosed by percutaneous needle biopsy (patient 1) and MRI scan (patient 2), demonstrating aberrant feeding artery from the abdominal aorta.
The postnatal courses of both lesions (figures) on serial ultrasound demonstrated that whilst their morphology remained unchanged, both lesions started to involute within months, in one patient completely resolving at 18 months (on CT scan) and in the other regressing to 1.3% of its original volume at 13 months. Both patients remained asymptomatic throughout their antenatal and postnatal history (mean follow-up 33 months) and neither required any further treatment.
Conclusions: Intra-abdominal PSs can involute spontaneously after birth. This is relevant for (i) antenatal counselling, and (ii) following confirmation of the diagnosis, serial ultrasound monitoring may obviate unnecessary surgery in asymptomatic patients.